Balance billing, sometimes also called extra billing, is the practice of a healthcare provider billing a patient for the difference between what the patient's health insurance chooses to reimburse and what the provider chooses to charge.

Advocates of balance billing argue that it increases the incomes of high-quality healthcare providers, and serves as a measure of their dissatisfaction with insurance company fees.[1] Critics say that balance billing lets providers raise charges through stealth rather than transparent pricing, creates unnecessary administrative costs and patient confusion, and allows insurers to simply pass along costs to patients, rather than helping them to secure good value.[2] It is thought to erode political consensus in favour of a one-tier system of healthcare, and to inhibit some people from getting the care they need, by making that care more expensive.[3]

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Throughout the 1970s in Canada, the country saw an increase in balance billing, which in Canada is normally called extra-billing. It was not permitted in Quebec or British Columbia, but had been encouraged in Ontario and Alberta, and tolerated in other provinces. The federal government estimated that by 1983, extra-billing across Canada totalled $100 million. The government believed that extra-billing was enabling the creation of a two-tiered Canadian healthcare system, in which people who couldn't afford extra charges would receive lesser care. In 1984, the government passed the Canada Health Act promising universal and comprehensive health coverage for all Canadians, which contained provisions to discourage user fees and extra-billing by imposing financial penalties on, and reducing transfer payments to, provinces which permitted them.[4][5][6] Today, five provinces prohibit all extra-billing, while Alberta, British Columbia and Newfoundland allow it in a small number of circumstances, and Prince Edward Island and New Brunswick do not restrict it at all.[7]

In France, physicians who want to charge more than the government-negotiated set fees are considered to be in a separate "payment sector," which essentially means they are treated as self-employed. They can charge higher fees, and receive reduced benefits. In 1987, about 27% of French physicians chose to balance bill. The percentage is higher for specialists rather than generalists, and for doctors in urban rather than rural areas.[8]

Balance billing is prohibited in Taiwan, and extra fees have only been allowed recently, and in rare defined circumstances. Today, patients in Taiwan are allowed to choose more expensive versions of some devices such as stents, implants or prosthetics, and to pay the difference in cost themselves.[11]